Ultrasound as an adjunct to radiography in minor musculoskeletal pediatric trauma.

PURPOSE: To assess the value of ultrasound as an adjunct to radiography in minor musculoskeletal pediatric trauma. METHODS: Fifty children with 53 suspected fractures were referred for upper and/or lower limbs X-rays, followed by ultrasound. On radiography, we noted presence of fracture, of soft tissue thickening, or absence of any lesion. On ultrasound, we noted presence of fracture, of soft tissue lesion, or absence of lesions. RESULTS: A fracture was seen on both examinations in 25 patients with 28 fractures.In 4 patients where only soft tissue thickening was seen on radiography, ultrasound showed fracture in 1 patient, hematoma in 1 patient and was normal in 2 patients. In another patient with a doubtful diagnosis of fracture on radiography, ultrasound was normal. In 20 patients with normal X-rays, ultrasound showed fracture in 6 patients, hematoma in 7 patients and was normal in 7 patients. CONCLUSION: Ultrasound was helpful as an adjunct to radiography, it yielded additional bone (7/50 patients) and soft tissue (8/50 patients) diagnostic information in 30% of patients. However, ultrasound remains operator-dependent and can be used only in particular circumstances, especially in children with normal X-rays and a high index of clinical suspicion for an occult or subradiological fracture.

Characterization of papillary projections in benign versus borderline and malignant ovarian masses on conventional and color Doppler ultrasound.

OBJECTIVE: The purpose of our study was to evaluate on endovaginal ultrasound the morphologic and color Doppler characteristics of papillary projections in benign compared with borderline and malignant epithelial stromal ovarian tumors. MATERIALS AND METHODS: A total of 283 women (mean age, 52 years; age range, 20-85 years) with 343 operated adnexal masses comprising 167 epithelial stromal tumors of the ovary with 76 tumors containing papillary projections at pathology were retrospectively studied on ultrasound. We systematically evaluated the topography of the papillary projections, the morphologic features of the largest papillary projection, and the presence or absence of color Doppler findings. All these findings were correlated with macroscopic and microscopic features. RESULTS: Ultrasound detected papillary projections in 78% of tumors. Papillary projections were disseminated in 33% of malignant, 20% of borderline, and 0% of benign tumors (p = 0.0049). The mean size of the papillary projections was 9.6, 15.7, and 35.3 mm in benign, borderline, and malignant tumors, respectively (p = 0.0007). An acute angle was present in 68% of benign tumors and an obtuse angle in 40% of borderline and 89% of malignant tumors (p = 0.0001). The surface was regular in 77% of benign tumors and irregular in 50% of borderline and 88% of malignant tumors (p = 0.0000). Calcifications were present only in benign tumors (18%). For papillary projections ≥ 10 mm, color flow was present in all malignant, in 86% of borderline, and absent in all benign tumors. CONCLUSION: Association of morphologic and vascular ultrasound findings can highly suggest the diagnosis of benign or malignant papillary projection.

History of mastectomy before and after Halsted.

The operation described by Halsted, in 1894 and called radical mastectomy, represents a milestone in the treatment of breast cancer. It consisted of removal of the breast, muscles and axillary lymph nodes. The pre-Halsted era saw attitudes ranging from the willful abstention to brutal treatments by cauterization or amputation. The introduction of anesthesia and asepsis enabled more advanced surgical attempts. The stratification of patients into operable and nonoperable categories has improved surgical outcome. After attempts to extend Halsted procedure (by extended or super-radical mastectomies) proved to be of little benefit, a minimally-invasive trend emerged gradually. It started with modified radical mastectomy that spares the muscles and was then followed by breast conservative surgery that leaves breast tissue behind. Then sentinel lymph node mapping was introduced with the hope of reducing the extent of axillary dissection. Finally, skin sparing mastectomy appeared in order to conserve skin and facilitate breast reconstruction.

The multiple ultrasound patterns of ectopic pregnancy.

Ectopic pregnancy (EP) has a variable and misleading clinical presentation contributing to the confusion with medical or other gynecological disorders. The rapid recourse to diagnostic methods, human chorionic gonadotropin (beta-hCG) titers and transvaginal ultrasonography, represents the best approach not only in the early diagnosis but also in the management and monitoring of patients with diagnosed EP. The purpose of this article is to provide a pictorial essay about EP and its multiple ultrasound (US) patterns. We present a large spectrum of EP aspects diagnosed on US and confirmed by pathology. We also review miscellaneous gynecologic diseases that may mimic EP on US. Although endovaginal US combined with quantitative (beta-hCG) analysis is an excellent tool for identifying EP, it may be normal sometimes in early pregnancies. Knowledge of all these patterns is helpful in establishing an early correct diagnosis, therefore leading to elective and conservative management in stable patients and preventing tubal rupture or substantial hemorrhage.

Retroperitoneal lymphangioleiomyoma mimicking ovarian tumor emerging after tamoxifen therapy.

BACKGROUND: Lymphangioleiomyomas are lymphatic masses that can be associated with lymphangioleiomyomatosis. They are usually associated with pulmonary involvement. CASE: A 44-year-old premenopausal woman with breast cancer treated with adjuvant tamoxifen presented with abdominal distension. A thoraco-abdominopelvic enhanced computed tomography scan showed a 22 x 21 x 12 cm well-encapsulated, complex pelvic mass. An ovarian cystadenocarcinoma was suspected. Surgery revealed a retroperitoneal mass that was removed with uterus and both adnexae. Histological and immunohistochemical studies diagnosed a lymphangioleiomyoma. Estrogen and progesterone receptors were positive on smooth muscle cells and human melanoma black 45 was negative. CONCLUSION: Isolated retroperitoneal lymphangioleiomyoma is rare and difficult to detect in the absence of pulmonary lymphangioleiomyomatosis. We speculate that tamoxifen treatment may play a role in the development of this benign tumor.

Spontaneous detorsion of the ovary: can it be diagnosed by MRI?

PURPOSE: To determine whether recent progress in imaging has made it possible to diagnose spontaneous detorsion, which is an accepted concept in the gynecological literature but until now has been a presumptive diagnosis that could not be confirmed because of the lack of imaging proof. MATERIALS AND METHODS: We searched for patients who had a diagnosis of spontaneous detorsion on MRI between January 2000 and January 2003, and selected only patients who met a selection of strict criteria, including mainly enlargement and hyperintensity of ovarian stroma on T2-weighted (T2W) images, clinical findings compatible with torsion and detorsion, and return of the stroma to normal size on follow-up examinations. Other signs of torsion, such as tubal thickening, were appreciated but not mandatory. Clinical follow-up for at least three years was available. RESULTS: Four patients met the study criteria. No stabilizing procedure was performed in the ovaries. One patient recurred and lost her ovary. CONCLUSION: The diagnosis of torsion followed by spontaneous detorsion was made with high probability in a selected number of patients. The clinical management of such patients remains a matter of debate. Laparoscopy with oophoropexy would be useful for young patients in whom close follow-up cannot be achieved.

Variable MR findings in ovarian functional hemorrhagic cysts.

PURPOSE: To describe the magnetic resonance (MR) findings in ovarian functional hemorrhagic cysts (FHC). MATERIALS AND METHODS: A total of 21 patients with 22 FHC, proven by follow-up ultrasound (US) in 11 women and surgery in 10 women, had US and MR examinations within 24 hours. The study was limited to cysts with obvious an echogenic pattern. All patients had T2-weighted fast spin echo (FSE), T1-weighted spin echo (SE), and T1-weighted SE fat-suppressed sequences. RESULTS: Four cysts (18%) were hypointense on T1-weighted-images without and with fat suppression, and hyperintense on T2-weighted-images. Five cysts (23%) were hypointense on T1-weighted images without and with fat suppression but heterogenous on T2-weighted images. Five cysts (23%) were hypointense on T1-weighted images but showed intermediate signal intensity on T1-weighted fat suppression images and heterogenous signal intensity on T2-weighted images. Two cysts (9%) were entirely intermediate on T1-weighted images. Five cysts (23%) displayed high signal intensity occupying less than 30% of the cystic content on T1-weighted images and one cyst (5%) displayed high signal intensity occupying more than 30% of the cystic content. CONCLUSION: Despite an obvious echogenic pattern on US, 64% of FHC were hypointense on T1-weighted images and 18% were also hyperintense on T2-weighted images. Only 36% demonstrated intermediate or high signal intensity on T1-weighted images.

Multilocular adenomatoid tumor of the ovary: ultrasonographic findings.

We report the sonographic findings of a rare benign ovarian tumor in a 69-year-old woman. Transvaginal ultrasonography showed a cystic multilocular lesion with a vascularized central solid portion of the left ovary. Surgery revealed an adenomatoid tumor. Adenomatoid tumors are benign lesions of mesothelial origin, usually solid in nature and rarely located in the ovaries. (c) 2005 Wiley Periodicals, Inc. J Clin Ultrasound 33:233-236, 2005.

Extraovarian cystadenomas: ultrasound and MR findings in 7 cases.

OBJECTIVE: To describe the ultrasound and MR appearance of paraovarian cystadenomas. METHODS: We reviewed retrospectively the radiologic findings in 7 patients with surgically proven paraovarian cystic neoplasms, including 6 serous cystadenomas and 1 borderline seromucinous cystadenoma. All had ultrasound and 4 had MR preoperatively. RESULTS: On ultrasound, the ipsilateral ovary was visualized in six cases, in contact with the cyst in five and separate from it in one. On MR, the ovary and the cyst were visible in four cases, in contact in three and separate in one. Internal papillary excrescences, present at pathology in all cysts, were seen in five on ultrasound and in four on MR. CONCLUSION: Although the extraovarian location of these neoplasms is difficult to determine preoperatively by ultrasound and MR, these imaging modalities are more reliable in predicting the histology of these rare lesions and differentiating them from simple paraovarian cysts.

Vesicouterine fistulas: imaging findings in three cases.

OBJECTIVE: The objective of our report is to present three cases of vesicouterine fistulas secondary to a cesarean delivery, a uterine rupture during labor, and radiation therapy. The delay between the onset of symptoms and the diagnosis varied between 3 and 7 years. Different techniques such as color Doppler sonography, excretory urography, cystography, CT, MRI, cystoscopy, vaginoscopy, and hysterography were performed with variable results, mostly negative and sometimes undefined. CONCLUSION: The definitive diagnosis was made with contrast-enhanced helical CT after cystography in one case, unenhanced helical CT after hysterography in another case, and cystography in the third case. Vesicouterine fistula rarely is thought of in the differential diagnosis because of its rarity and negative results on radiologic and endoscopic tests. The diagnosis is made on imaging after opacification of the uterus or the bladder depending on the pressure gradient obtained and the location of the fistula in relation to the uterine isthmus.

Adnexal torsion: magnetic resonance findings in the viable adnexa with emphasis on stromal ovarian appearance.

PURPOSE: To evaluate ultrasound (US) and magnetic resonance (MR) findings in the viable twisted adnexa. MATERIALS AND METHODS: Ten patients underwent US and MR studies before surgical detorsion. Corrected cross-sectional area of the ovary was defined as cross-sectional area minus areas of cysts and follicles superior to 1 cm. On T2-weighted images, signal intensity of the stroma was graded as type 1 when it was equal to that of urine and type 2 when it was less than that of urine but markedly more than the contralateral side. RESULTS: The tube was twisted in six cases and the ovary in nine cases. All adnexa were viable. The largest ovarian cross-sectional area and the largest corrected ovarian cross-sectional area of the twisted ovary were significantly larger than those of the contralateral ovary (P = 0.043 for US; P = 0.012 and 0.017, respectively, for MR). These ovaries contained types 1 and 2 hyperintensity in six cases and only type 2 hyperintensity in three cases. Tubal thickening was seen on MR in five cases. CONCLUSION: Tubal thickening, enlargement of ovarian stroma as reflected by the corrected cross-sectional area, and hyperintensity of this stroma on T2-weighted images probably related to edema were useful findings in these viable torsions.